Professor Kruglov Sergey Vladimirovich - surgeon

Professor Kasatkin Vadim Fedorovich-surgeon-oncologist

Alubaev Sergey Alexandrovich - candidate of medical sciences, surgeon of the highest category.

Bova Sergey Ivanovich - surgeon-urologist of the highest category.

Page editor: Kryuchkova Oksana Aleksandrovna

In the clinical picture of postoperative suppuration, depending on the pathogens, several variants of the course can be distinguished. With staphylococcal infection, the body temperature begins to rise on the 5-7th day. Sometimes fever is noted as early as the 1st day after surgery. The patient's state of health worsens. Begin to disturb the pain in the area of \u200b\u200bthe wound, varying in intensity. When examining the wound, attention is drawn to the swelling of the edges, sometimes hyperemia of the skin, pain on palpation of the surrounding tissues, infiltration of subcutaneous fat. With the localization of suppuration under the aponeurosis, the skin and subcutaneous fatty tissue begin to respond only when pus spreads to these layers of the wound. This circumstance delays timely diagnosis. It must be remembered that after some operations (appendectomy, resection of the stomach, colon), suppuration, as a rule, spreads from the depth of the surgical wound.

With gram-negative flora, especially with Pseudomonas aeruginosa infection, general and local manifestations of suppuration begin on the 3-4th day. These patients have more pronounced general intoxication, fever, tachycardia, pain syndrome. With non-clostridial anaerobic infection (non-spore-forming microbes that grow under anaerobic conditions), fever is usually noted from the 1st day after surgery. General anxiety of the patient, sharp pain in the area of \u200b\u200boperation, early edema of surrounding tissues, severe tachycardia, vomiting, diarrhea are characteristic. Dilution of the edges of the wound in some cases does not stop suppuration. It tends to spread in the subcutaneous adipose preperitoneal tissue in the form of a phlegmonous process that requires special surgical tactics.

Rarely, but Clostridial wound infection is still observed. In such cases, in the first hours, less often on the 1st day after the operation, intoxication phenomena are pronounced: high body temperature, chills, the appearance of jaundice (at first only the yellowness of the sclera), oliguria,

tachycardia, shortness of breath, agitation, and then confusion. These phenomena are growing rapidly. Local manifestations (pain in the wound area, swelling, crepitus, dark blue spots on the skin) are detected later.

Early infection is characterized by high leukocytosis and, most importantly, lymphopenia, which may be an indicator of a developing complication. As a rule, a drop in the lymphocyte count to 5-7% indicates that suppuration should be expected. A. L. Kostyuchenko et al. (1985) believe that severe lymphopenia (absolute concentration below 0.5-109 / l) is an important prognostic indicator indicating the possibility of wound suppuration in the postoperative period.

After diluting the edges of the wound, as a rule, they specify both the prevalence of the process and, to some extent, the nature of the pathogen (Table 8.2). Staphylococcal infection is characterized by thick, creamy odorless pus, necrosis of the surface layers of tissue and aponeurosis. With Pseudomonas aeruginosa, initially thick pus with a specific odor in the coming days becomes liquid, stains the dressing in a blue-green color with stains along the edges. Granulations with Pseudomonas aeruginosa occur late, they are lethargic, pale, easily vulnerable, bleed. If, with staphylococcal infection, the reaction, pus is weakly acidic or neutral (pH 6.8-7.0), then with Pseudomonas aeruginosa infection, an alkaline reaction is expressed. When the wound is irradiated with ultraviolet rays, fluorescence is detected.

In recent years, the attention of surgeons has been drawn to the non-clostridial microflora as the cause of many postoperative complications. When the edges of such a wound are diluted, attention is drawn to extensive necrosis of cellulose, aponeurosis, liquid fetid pus. When plated on conventional media, no growth was detected. Only on special media under anaerobic conditions can the growth of anaerobic microbes be seen. Since the method of detecting anaerobic flora is not possible to apply in all clinics, one should pay attention to the complex of symptoms of anaerobic infection. In addition to characteristic changes in the wound, a bacterioscopic examination can help diagnose, in which gram-positive rods are found. With such an infection, the process is often not limited to the wound, but

Table 8.2. Clinical signs of various types of infection

there is a tendency to spread in the form of putrefactive phlegmon of the anterior abdominal wall. Such phlegmon have the following clinical features: 1) rapid spread, large area of \u200b\u200bdamage and the severity of the clinical picture; 2) not expressed, as a rule, hyperemia; 3) slight swelling of the skin; 4) pronounced tachycardia and yellowness of the sclera. It should be emphasized that with anaerobic infection, bacterial shock is often observed, which sometimes acquires an irreversible course and is the direct cause of death of most patients.

Not only dissection, but, if possible, excision of the affected subcutaneous fatty tissue with simultaneous anti-shock and intensive antibacterial treatment can give positive results.

In our practice, we observed 10 patients with severe phlegmon of the anterior abdominal wall after various operations; 2 of them died. As a rule, E. coli was found in the wound cultures, and gram-positive bacilli were found during bacterioscopy.

It should be emphasized that when the edges of the wound are diluted, the process is not stopped. Incisions through the affected area are also ineffective. Only extensive incisions through necrotic healthy tissue can halt the spread of infection. When treating such wounds, oxygenation with oxygen should be carried out, dressings with a solution of potassium permanganate, hydrogen peroxide, large doses of penicillin (up to 60,000,000 IU per day intramuscularly) should be used. Antibiotics of a broad spectrum of action are also shown: 1 g of ceporin in combination with gentamicin 80 mg 3-4 times a day intramuscularly. Metronidazole is prescribed at 0.5-2 g per day. Infusion therapy is carried out to reduce intoxication.

As an example, we give a clinical observation.

Patient M., 27 years old, was operated on in the clinic for acute phlegmonous appendicitis. On the 3rd day after the operation, the body temperature increased, tachycardia appeared. The skin around the wound in the right iliac region is edematous, there is also a sharp pain on palpation. After removing the stitches from the skin, thick, fetid pus came out. Aponeurosis in a state of necrosis. Tampons with hypertonic sodium chloride solution were inserted into the wound.

The next day, the swelling of the skin increased, the body temperature remained high. Two incisions were made in parallel to the surgical wound. The subcutaneous fatty tissue at the site of the incisions is saturated with pus. The wounds were made with tampons soaked in potassium permanganate solution. Within 2 days the condition did not improve, the intoxication increased. When sowing pus, no growth was noted. During bacterioscopy, gram-positive rods were identified. Under anesthesia, four additional incisions were made on the anterior abdominal wall, in the lateral and gluteal regions along healthy tissue sites. These incisions are connected under the skin to the previous ones. Penicillin was prescribed at 40,000,000 IU per day intramuscularly. The patient recovered.

We emphasize once again that with such phlegmons of the anterior abdominal wall, incisions only in altered tissues are unsuccessful. Only the incisions bordering the lesion ensure sufficient drainage of the wound and prevent the spread of the process.

The basic laws of purulent surgery in the treatment of purulent wounds remain unshakable: 1) the wound should be opened to the bottom in such a way that no pockets and leaks remain; 2) all possible ways of spreading the purulent process from the main focus should be under constant control and, at the slightest suspicion of the possibility of suppuration, undergo surgical revision; 3) it is necessary to fight the microflora by physical and chemical means in order to suppress it; 4) to influence the macroorganism to increase the protective forces.

The currently existing methods of surgical treatment of purulent wounds can be grouped as follows.

1. A method based on the excision of purulent-necrotic tissues by the type of primary surgical treatment. Drainage, suturing over the drainage, further washing with various antiseptics with constant active aspiration. It is clear that this method is not always applicable (in particular, with deep suppuration of the chest and abdominal walls), sometimes it is fraught with the possibility of rapid spread of the purulent process to the surrounding tissues.

2. Combination of surgical treatment (complete or partial) with physical impact on the wound process: laser, X-ray, ultrasonic irradiation of the wound surface using aseptic dressings and subsequent secondary sutures.

3. Traditional method: dilution of the wound edges, drainage, use of antiseptics, and at the stage of granulation - various ointment dressings, application of secondary sutures according to indications.

In the treatment of purulent wounds in the first phase of the wound process, proteolytic enzymes are now widely used, in the second phase - inhibitors of proteolytic enzymes. Of the inhibitors, 5% e-aminocaproic acid ointment on petroleum jelly or lanolin is used. 10% methyluracil ointment has proven itself well. The choice of medicine depends on the flora. So, with suppuration caused by Pseudomonas aeruginosa, drugs with an acid reaction should be used - 1% solutions of acetic or boric acid. In case of anaerobic infection, it is advisable to use hydrogen peroxide, potassium permanganate. Among modern antiseptic agents, dioxidia, chlorhexidine, dimexide, chlorophyllipt, etc. are effective in treating wounds.

In patients preparing for surgery, the oral cavity must be sanitized, and concomitant foci of infection must be eliminated. One should strive for adequate treatment of the operating field with modern antiseptics. More details on the prevention of nosocomial infection are described below.

Sepsis is the most severe complication of the postoperative period. Its frequency has increased in connection with intravascular and intracardiac interventions. For the general surgeon, the possibility of sepsis during catheterization of large veins is of particular importance. Dozens of papers have been published on angiosepsis.

The clinical picture of sepsis is diverse. Angiosepsis is characterized by the initially latent course of the complication, since there are no local inflammatory phenomena. However, the patient's condition gradually deteriorates: chills appear, an increase in body temperature of a hectic nature, torrential sweat after a decrease in temperature, increased leukocytosis with a stab shift, lymphopenia, eosinophilia, and further anemia. The spleen is enlarged. Characterized by yellowness of the sclera and skin. The more pronounced the jaundice, the more difficult the general condition of the patient. A poor prognostic sign is thrombocytopenia, which is accompanied by hemorrhages in the skin and mucous membranes. Gastric and intestinal bleeding may occur.

In the stage of septicemia, purulent foci are formed in other organs, most often in the lungs, liver, kidneys. A characteristic feature of pulmonary septic foci is the absence of abundant purulent sputum in the presence of multiple decay cavities. The latter are initially localized, as a rule, in the lower lobes, and then they can capture all parts of the lungs. Subpleural septic foci located subpleurally often open into the pleural cavity, resulting in pyothorax, which sharply worsens the patient's condition and, of course, the prognosis. The clinical picture, along with symptoms of intoxication, is characterized by signs of respiratory failure: shortness of breath, cyanosis, marbling of the skin.

The appearance of intrahepatic foci is accompanied by chills and increasing liver failure. In the blood, the level of bilirubin, transaminases rises sharply, the content of albumin falls. Hepato-renal syndrome is often associated, manifested by oliguria, anuria, high levels of urea and creatinine in the blood. The emergence of septic foci in

kidney leads to pyuria and an increase in renal failure. Cortically located foci break through into the perirenal tissue with the development of paranephritis.

Treating sepsis is very challenging. The therapy is based on broad-spectrum antibiotics. Of great importance is the study of microflora for sensitivity to antibiotics, followed by the appointment of appropriate drugs. V.D.Belyakov et al. (1976) recommend large doses of penicillin (up to 100,000,000 units per day). With Pseudomonas aeruginosa sepsis, penicillin is combined with pyopenic (up to 30 g), ampicillin (8-12 g) or kanamycin (3-4 g). Antibiotics are recommended to be given intravenously every 3-4 hours. Recently, many authors recommend intra-arterial antibiotics.

In our practice we used penicillin (up to 40,000,000 IU per day), as well as gentamicin in a daily dose of 80-160 mg, ampicillin - 8 g, kefzol - 3-4 g, seporin - 8 g. Approximately after 7-10 days the antibacterial drug was changed. In the treatment of sepsis, of course, all the possibilities of intensive care should be used: transfusion of freshly preserved blood, administration of antistaphylococcal gamma globulin, plasma, vitamins, elimination of hypovolemia, electrolyte and protein disorders, changes in CBS. We observed 12 patients with sepsis; in 4 of them it was caused by catheterization of the subclavian vein. In all 12 patients, the clinical picture of sepsis was characterized by three common features: the presence of septic foci in the internal organs, the hematogenous nature of their occurrence, and the detection of microbes in the blood. Here is a clinical observation.

Patient V., 33 years old, underwent a course of hemosorption for psoriasis. The catheter in the left subclavian vein was kept for 2 weeks. By the end of this period, the body temperature suddenly rose to 39 ° C, quickly acquired a hectic character, chills and torrential sweat were observed. The catheter is removed. In the very first days after the rise in temperature, chest radiographs showed a darkening in the lower lobe on the right, and a few days later the decay cavity on the right and darkening in the lower lobe on the left were clearly visible. Blood culture revealed pathogenic aureus Staphylococcus aureus, sensitive to ceporin and gentamicin. There was an enclosed empyema of the pleural cavity on the right. Treatment: kefzol 2 g per day for 10 days, then gentamicin 160 mg per day intravenously for 10 days, after the last cancellation ampicillin intravenously 6 g per day for 10 days. Conducted daily puncture of the pleural cavity with the introduction of antibiotics. Freshly preserved blood, plasma, vitamins were transfused. Antistaphylococcal plasma was injected three times. Gradually, the patient's condition began to improve. The decay cavity in the right lung and the darkening in the lower lobe on the left disappeared. The patient was discharged on the 50th day from the onset of complications.

Of the 12 patients we observed, 7 died. As a rule, the deceased had multiple purulent foci in the liver, kidneys and other organs. The success of treatment depends mainly on the early diagnosis of sepsis and adequate antibiotic therapy.

Suppuration of the Wound - Suppuration of an operating wound (suppuration of a postoperative wound, or suppuration of a seam) today has a number of features. First of all, the frequency of this complication increased (according to many authors, from 1 to 15% or more - A.I. Gnatyshak and L.R. Kryshtalskaya, 1967; B.V. Petrovsky, 1971; V.A.Proskurov, 1974; Altemeier , 1970; Bruun, 1970; Grun 1974; Brock, 1975, and others; 5.4% of all operations in our observations). The increase in the number of suppurations, in addition to the general reasons for the growth of hospital infections, can be explained by a number of factors:

the initial state of the patient and his unsatisfactory protective reaction;

complications that developed during the operation and in connection with errors in the operational technique;

infection of the wound during or after surgery.

Depending on the localization of suppuration, various variants of the clinical course were noted. On the chest, the purulent process is usually more severe than on the abdominal wall or limbs. A particularly severe clinical course was observed with wound suppuration after operations with artificial circulation. In this group of patients, the reactivity and immunological properties of the organism change significantly. The inflammatory reaction slows down, becomes inferior, all reparative processes are disrupted. In this regard, there was often a divergence of sutures and rapid infection of wounds, the phenomenon of hemorrhagic diathesis (in the form of multiple small hematomas along the wound). Granulation growth and healing were significantly slowed down. Lagging of regenerative processes in wounds after operations with artificial circulation led to lengthening the time of their healing. Histological examination of the wound edges showed a sharp decrease in the number of leukocytes and histiocytes. Fibroblasts and fibers of fibrous tissue were pathologically changed: hypertrophied fibroblasts and thickened fibers appeared. Damage to the vascular wall, areas of hemorrhage and hematomas were also observed. The wound surfaces were covered with a gray bloom, and gave off a putrid odor.

Thus, after operations with artificial circulation, the wounds have some features due to a mild inflammatory reaction and a slowdown in regeneration. A similar course of the wound process was observed during organ transplantation with the use of immunosuppressants, after severe trauma, in patients with congenital or acquired immunological insufficiency. These circumstances led to a high frequency of wound suppuration in them.

According to the clinical course, patients with wound suppuration can be divided into three groups. In patients of the first group, local symptoms were expressed. General health did not suffer significantly. Only a temperature reaction was noted. The outcome was generally good. In the second group, a more severe general course was noted, accompanied by severe intoxication, secondary exhaustion, and prolonged healing. In patients of the third group, wound suppuration progressed, the process spread to the surrounding tissues, often joined by peritonitis, mediastinitis, pleural empyema, pneumonia, sepsis and other complications, accompanied by septicemia, septic shock. They were preceded by one or another degree of unresponsiveness. The forecast has always been serious.

Suppuration of the wound usually proceeded with the second wave of temperature rise (on the 5th - 8th day with staphylococcus, on the 3rd - 5th - with Pseudomonas aeruginosa). Prolonged fever, beginning from the first postoperative day, was more often observed. Local signs of inflammation were somewhat delayed in time and were detected on the 7th - 8th day with staphylococcus, on the 3rd - 4th day with Pseudomonas aeruginosa. Most patients, even before the appearance of local phenomena, noted a deterioration in health, pain in the wound, fever, sometimes chills, tachycardia, shortness of breath. The temperature rose to 38 ° C and higher. On examination and palpation, it was possible to detect pastiness and infiltration of the edges of the wound, in some cases areas of hyperemia and its soreness. Pus oozing between the stitches was sometimes noted. After removing the sutures, the edges easily diverged, the edematous subcutaneous fat, covered with a gray bloom, was exposed, a turbid hemorrhagic fluid or pus was released.

In cases of wound infection caused by Pseudomonas aeruginosa, fibrinous-purulent inflammation was superficial, the pus was initially thick, viscous. On the 3rd - 4th day after dilution of the edges of the wound, the nature of the discharge began to change. The pus became more liquid, its color acquired a characteristic greenish-yellow hue, which is associated with the formation of a blue-green pigment - pyocyanin, which is released only under aerobic conditions. Therefore, the blue-green color of the dressings, especially their superficial layers, is a very characteristic sign for local Pseudomonas aeruginosa infection. Flaccid, pale granulations bleed easily. A specific smell appeared, which was sometimes noted from the first day.

When determining the pH of purulent wounds using a universal indicator paper, it was found that Pseudomonas aeruginosa infection gives an alkaline reaction (pH 8.5 - 9.0), with staphylococcal suppuration, the reaction is weakly acidic or neutral (pH 6.8 - 7.0).

Thus, the following signs are characteristic of suppuration of a wound of Pseudomonas aeruginosa: 1) staining of the surface layers of the dressing 1 - 2 days after dressing in a blue-green color; 2) copious liquid purulent discharge of blue-green color with a specific odor; 3) flaccid, pale, easily bleeding granulations with significant edema and swelling of the edges of the wound; 4) fluorescence in case of irradiation with long-wave rays in a darkened room; 5) alkaline reaction of the wound (pH more than 8.5).

In combination of several pathogens, Pseudomonas aeruginosa helps to obtain a predominance of the use of antibiotics, to which it remains the most resistant.

Morphological changes in most cases of wound suppuration were of the same type. The postoperative chest wound was a gaping opening with necrotic margins soaked in pus, sometimes with exposed ribs and scapula. The spread of the process to the surrounding tissues led to rib chondritis or osteomyelitis. In some cases, the infiltration spread to the diaphragm. Often there was a communication with the pleural cavity, pleural empyema developed. With a median approach, fibrinous-purulent inflammation passed to the anterior mediastinum, penetrating in some cases into deeper tissues and giving a picture of purulent mediastinitis, pericarditis, and sometimes osteomyelitis of the sternum. Suppuration of the postoperative wound of the anterior abdominal wall, spreading beyond the aponeurosis, could lead to communication with the abdominal cavity, peritonitis, eventration.

134. How is mechanical ventilation (artificial ventilation of the lungs) carried out "from mouth to mouth", "from mouth to nose" using the "AMBU" apparatus?

Artificial lung ventilation

I Artificial lung ventilation

provides gas exchange between the ambient air (or a specially selected mixture of gases) and the alveoli of the lungs.

Modern methods of artificial lung ventilation (ALV) can be conditionally divided into simple and hardware. Simple methods are usually used in emergency situations: in the absence of spontaneous breathing (apnea), with an acutely developed violation of the rhythm of breathing, its pathological rhythm, agonal breathing: with an increase in breathing rate of more than 40 per 1 min, if this is not associated with hyperthermia (body temperature is higher 38.5 °) or severe unrepaired hypovolemia; with increasing hypoxemia and (or) hypercapnia, if they do not disappear after anesthesia, restoration of airway patency, oxygen therapy, elimination of a life-threatening level of hypovolemia and gross metabolic disorders. The simple methods primarily include expiratory ventilation (artificial respiration) from mouth to mouth and from mouth to nose. In this case, the head of the patient or the victim must be in the position of maximum occipital extension (Fig. 1) to prevent tongue retraction and ensure airway patency; the root of the tongue and the epiglottis are displaced anteriorly and open the entrance to the larynx (Fig. 2). The person providing assistance stands to the side of the patient, squeezes the wings of his nose with one hand, tilting his head back, with the other hand slightly opens his mouth behind the chin. Taking a deep breath, he tightly presses his lips to the patient's mouth (Fig. 3) and makes a sharp, energetic exhalation, after which he moves his head to the side. The patient exhales passively due to the elasticity of the lungs and chest. It is desirable that the mouth of the caregiver be insulated with a gauze pad or piece of bandage, but not with a thick cloth. During mechanical ventilation, air is blown from the mouth into the nose into the patient's nasal passages (Fig. 4). At the same time, his mouth is closed, pressing the lower jaw to the upper and trying to pull the chin up. Air injection is usually carried out with a frequency of 20-25 per minute; when combined with mechanical ventilation with cardiac massage (see Resuscitation) - with a frequency of 12-15 in 1 min. Simple mechanical ventilation is greatly facilitated by the introduction of an S-shaped air duct into the patient's oral cavity, the use of a Ruben bag (Ambu, RDA-1) or RPA-1 fur through an oronasal mask. In this case, it is necessary to ensure airway patency and tightly press the mask to the patient's face.

Hardware methods (with the help of special respirators) are used when long-term mechanical ventilation is necessary (from several hours to several months and even years). In the USSR, the most common RO-6A in its modifications (RO-6N for anesthesia and RO-6R for intensive care), as well as the simplified model RO-6-03. The "Phase-50" respirator has great capabilities. The Vita-1 apparatus is produced for pediatric practice. The first domestic device for high-frequency jet ventilation is the "Spiron-601" respirator

The respirator is usually attached to the patient's airway through an endotracheal tube (see Intubation) or a tracheostomy cannula. Most often, mechanical ventilation is performed in the normal frequency mode - 12-20 cycles per minute. The practice also includes mechanical ventilation in a high-frequency mode (more than 60 cycles per 1 min), in which the tidal volume is significantly reduced (up to 150 ml or less), the positive pressure in the lungs at the end of inspiration and intrathoracic pressure decrease, and the blood flow to the heart is less difficult. In addition, with mechanical ventilation in a high-frequency mode, the patient's habituation (adaptation) to the respirator is facilitated.

There are three methods of high-frequency ventilation (volumetric, oscillatory and jet). Volumetric is usually carried out with a respiration rate of 80-100 per 1 min, oscillatory - 600-3600 per 1 min, providing vibration of a continuous or intermittent (in normal frequency mode) gas flow. The most widely used jet high-frequency mechanical ventilation with a breathing rate of 100-300 per minute, in which a stream of oxygen or a gas mixture under a pressure of 2-4 atm is blown into the airways through a needle or catheter with a diameter of 1-2 mm. Jet ventilation can be performed through an endotracheal tube or tracheostomy (in this case, injection occurs - atmospheric air is sucked into the airways) and through a catheter inserted into the trachea through the nasal passage or percutaneously (puncture). The latter is especially important in cases where there are no conditions for tracheal intubation or the medical staff does not have the skill to carry out this procedure.

Artificial ventilation of the lungs can be carried out in an automatic mode, when the patient's spontaneous breathing is completely suppressed by pharmacological drugs or specially selected ventilation parameters. It is also possible to carry out auxiliary mechanical ventilation, in which the patient's spontaneous breathing is preserved. Gas is supplied after a weak attempt of the patient to inhale (trigger mode of auxiliary ventilation), or the patient adapts to an individually selected mode of operation of the apparatus.

There is also an intermittent mandatory ventilation (IPV) mode, commonly used during the gradual transition from mechanical ventilation to spontaneous breathing. In this case, the patient breathes on his own, but a continuous flow of a heated and humidified gas mixture is supplied to the respiratory tract, which creates a positive pressure in the lungs throughout the entire respiratory cycle. Against this background, at a given frequency (usually from 10 to 1 time in 1 min), the respirator produces an artificial breath that coincides (synchronized PPVL) or does not coincide (unsynchronized LLVL) with the patient's next spontaneous inhalation. The gradual delivery of artificial breaths prepares the patient for spontaneous breathing.

The mode of mechanical ventilation with positive end-expiratory pressure (PEEP) from 5 to 15 cm of water has become widespread. Art. and more (for special indications!), in which the intrapulmonary pressure during the entire respiratory cycle remains positive in relation to atmospheric. This mode promotes the best distribution of air in the lungs, a decrease in blood shunting in them and a decrease in the alveolar-arterial oxygen difference. With artificial ventilation with PEEP, atelectasis is straightened, pulmonary edema is eliminated or reduced, which improves oxygenation of arterial blood with the same oxygen content in the inhaled air. However, with positive pressure ventilation at the end of inspiration, the intrathoracic pressure increases significantly, which can lead to obstruction of blood flow to the heart.

The relatively rarely used method of mechanical ventilation - electrical stimulation of the diaphragm - has not lost its significance. By periodically irritating either the phrenic nerves or directly the diaphragm through the external or needle electrodes, it is possible to achieve its rhythmic contraction, which ensures inhalation. Electrostimulation of the diaphragm is often used as a method of auxiliary mechanical ventilation in the postoperative period, as well as in preparing patients for surgical interventions.

With modern anesthesia (see General anesthesia), mechanical ventilation is performed primarily in connection with the need to provide muscle relaxation with curariform drugs. Against the background of mechanical ventilation, it is possible to use a number of analgesics in doses sufficient for full anesthesia, the introduction of which under conditions of spontaneous breathing would be accompanied by arterial hypoxemia. By maintaining good oxygenation of the blood, mechanical ventilation helps the body cope with surgical trauma. In a number of surgical interventions on the organs of the chest (lungs, esophagus), separate intubation of the bronchi is used, which makes it possible to turn off one lung from ventilation during the operation to facilitate the work of the surgeon. Such intubation also prevents leakage of contents from the operated lung into the healthy lung. In surgical interventions on the larynx and airways, transcatheter jet high-frequency ventilation is successfully used, which facilitates the examination of the operating field and allows maintaining adequate gas exchange when the trachea and bronchi are opened. Considering that under conditions of general anesthesia and muscle relaxation, the patient cannot respond to hypoxia and hypoventilation, it is of particular importance to control the content of blood gases, in particular constant monitoring of the partial pressure of oxygen (pO2) and partial pressure of carbon dioxide (pCO2) by the percutaneous route with using special sensors. During general anesthesia in emaciated, debilitated patients, especially in the presence of respiratory failure before surgery, with severe hypovolemia, the development of any complications during general anesthesia that contribute to the occurrence of hypoxia (lowering blood pressure, cardiac arrest, etc.) within a few hours after the end of the surgery. In case of clinical death or agony, mechanical ventilation is a mandatory component of the resuscitation benefit. It can be stopped only after complete restoration of consciousness and full independent breathing.

In the complex of intensive therapy (Intensive therapy), mechanical ventilation is the most powerful means of combating acute respiratory failure. It is usually passed through a tube that is inserted into the trachea through the lower nasal passage or tracheostomy. Careful care of the airways and their complete drainage are of particular importance. With pulmonary edema (Pulmonary edema), pneumonia (Pneumonia), respiratory distress syndrome in adults (Respiratory distress syndrome in adults), artificial ventilation with PEEP is sometimes indicated up to 15 cm of water. Art. and more. If hypoxemia persists even with a high PEEP, the combined use of traditional and high-frequency jet mechanical ventilation is indicated.

Auxiliary mechanical ventilation is used in sessions up to 30-40 minutes in the treatment of patients with chronic respiratory failure. It can be used in outpatient clinics and even at home after appropriate patient training.

Mechanical ventilation is used in patients in a coma (trauma, brain surgery), as well as in peripheral lesions of the respiratory muscles (polyradiculoneuritis, spinal cord injury, amyotrophic lateral sclerosis). In the latter case, mechanical ventilation has to be carried out for a very long time - months or even years, which requires particularly careful patient care. Mechanical ventilation is widely used in the treatment of patients with chest trauma, postpartum eclampsia, various poisonings, cerebrovascular accidents, tetanus, and botulism.

Monitoring the adequacy of mechanical ventilation. When carrying out emergency mechanical ventilation using simple methods, it is sufficient to observe the color of the skin and movements of the patient's chest. The chest wall should rise with each inhalation and fall off with each exhalation. If, instead, the epigastric region rises, then the blown air does not enter the respiratory tract, but the esophagus and stomach. The cause is most often the wrong position of the patient's head.

When carrying out long-term mechanical ventilation, its adequacy is judged by a number of signs. If the patient's spontaneous breathing is not suppressed pharmacologically, one of the main signs is a good adaptation of the patient to the respirator. With a clear consciousness, the patient should not have a feeling of lack of air, discomfort. Respiratory sounds in the lungs should be the same on both sides, the skin is of the usual color, dry. Signs of inadequacy of mechanical ventilation are increasing tachycardia, a tendency to arterial hypertension, and when artificial ventilation with PEEP is used - to hypotension, which is a sign of a decrease in blood flow to the heart. It is extremely important to control pO2, pCO2 and the acid-base state of the blood; pO2 during mechanical ventilation should be maintained at least 80 mm Hg. Art. In severe hemodynamic disorders (massive blood loss, traumatic or cardiogenic shock), it is desirable to increase pO2 up to 150 mm Hg. Art. and higher. pCO2 should be maintained by changing the minute volume and respiratory rate at the maximum level at which the patient fully adapts to the respirator (usually 32-36 mm Hg). During prolonged mechanical ventilation, metabolic acidosis or metabolic alkalosis should not occur. The first most often indicates violations of peripheral blood circulation and microcirculation, the second - about hypokalemia and cellular hypohydration.

Complications. With prolonged mechanical ventilation, tracheobronchitis, pneumonia often occur; pneumothorax is a dangerous complication, because under mechanical ventilation, air rapidly accumulates in the pleural cavity, squeezing the lung, and then displacing the mediastinum. During mechanical ventilation, the endotracheal tube may slip into one of the bronchi (usually the right one). This often happens during transportation and movement of the patient.

During ventilation, a bulge may form in the inflatable cuff of the endotracheal tube, which covers the opening of the tube and prevents ventilation.

Features of artificial ventilation in pediatrics. Children, especially young children, easily develop laryngitis, laryngeal edema, and other complications associated with intubation. Therefore, they are advised to perform tracheal intubation with a tube without an inflatable cuff. Respiratory volume and respiratory rate are selected according to age and body weight. In newborns, a respiratory rate of 30-40 or more is set in 1 min. With asphyxiation of newborns, aspiration of meconium and breathing disorders caused by infantile cerebral palsy, along with traditional simple and hardware methods of mechanical ventilation, oscillatory high-frequency mechanical ventilation with a frequency of 600 or more per 1 min is successfully used.

Features of artificial lung ventilation in military field conditions. In military field conditions, as well as when providing assistance to victims of peacetime disasters (fires, earthquakes, accidents in mines, railway accidents, plane crashes), mechanical ventilation can be complicated by the presence in the atmosphere of various kinds of harmful impurities (toxic gases and combustion products, radioactive substances, biological agents, etc.). A person providing assistance, being in a gas mask, oxygen mask or protective suit, cannot resort to mechanical ventilation using the mouth-to-mouth or mouth-to-nose method. Even after taking the victim out of the affected area, it is dangerous to use these methods, because toxic or biological agents may already be in his lungs and enter the respiratory tract of the rescuer. Therefore, hand-held ventilators - self-expanding bags and furs - are of particular importance. All of them, as well as automatic respirators, should be equipped with special deactivating filters to prevent harmful impurities from entering the patient's respiratory tract. An exception is drugs for high-frequency jet ventilation, if they have an autonomous source of compressed gas and are used transcatheterically (without injection of ambient air).

Bibliography: Burlakov R.I., Galperin Yu.Sh. and Yurevich V.M. Artificial lung ventilation: Principles, methods, equipment, M., 1986, bibliogr .; Zilber L.P. Artificial ventilation of the lungs with acute respiratory failure, M., 1978, bibliogr .; Kara M. and Poyavere M. First aid for respiratory disorders caused by road trauma, poisoning and acute diseases, trans. with French., M., 1979; Kassil V.L. Artificial ventilation of the lungs in intensive care, M., 1987, bibliogr .; Popova L.M. Neuroreanimatology, p. 104, M., 1983; Smetnev A.S. and Yurevich V.M. Respiratory therapy in the clinic of internal diseases, M., 1984.

An artificial lung ventilator (ventilator) is a medical equipment that is designed to force a gas mixture (oxygen + compressed dried air) into the lungs in order to saturate the blood with oxygen and remove carbon dioxide from the lungs.

The ventilator can be used both for invasive (through an endotracheal tube inserted into the patient's airways or through a tracheostomy) and for non-invasive mechanical ventilation through a mask.

The ventilator can be either manual (“AMBU” bag) or mechanical. Compressed air for the operation of a mechanical device can be supplied both from the central gas supply system of a medical institution or a compressed air cylinder (during transportation), and from an individual mini-compressor (reality in the ex-USSR countries).

Modern ventilators are extremely high-tech medical equipment. They provide respiratory support to the patient in both volume and pressure. There are a variety of ventilation modes, including AUTOMODE, which allows the patient to transition from controlled breathing to spontaneous breathing.

Currently, the most advanced technology for synchronizing a ventilator with a patient is neuro-controlled ventilation of the lungs (NAVA technology; developed by Maquet), when the signal coming from the respiratory center of the medulla oblongata along the phrenic nerve to the diaphragm is recorded by special highly sensitive sensors located in the transition area esophagus into the stomach (cardia area).

The operation is the most important stage in the treatment of surgical patients, during which a methodical separation of tissues is performed, aimed at accessing the pathological focus in order to eliminate it. As a result, a wound is formed, which is characterized by three important symptoms: gaping, pain, bleeding.

The body has a perfect mechanism aimed at wound healing, which is called the wound process. Its purpose is to eliminate tissue defect and relieve the listed symptoms. This process is an objective reality and occurs independently, passing through three phases in its development: inflammation, regeneration, and reorganization of the scar.

The first phase of the wound process - inflammation - is aimed at cleansing the wound from non-viable tissues, foreign bodies, microorganisms, blood clots, etc. Clinically, this phase has symptoms characteristic of inflammation: pain, hyperemia, edema, dysfunction, fever.

Gradually, these symptoms subside and the first phase is replaced by the regeneration phase, the meaning of which is to fill the wound defect with young connective tissue. At the end of this phase, the processes of constriction (tightening of the edges) of the wound begin due to fibrous connective tissue elements and marginal epithelization.

The third phase of the wound process, the reorganization of the scar, is characterized by its strengthening and complete epithelialization of the wound surface.

The outcome in surgical pathology largely depends on the correct observation and care of the postoperative wound. The wound healing process is absolutely objective and worked out to perfection by nature itself. However, there are reasons that interfere with the wound process, inhibit the normal wound healing.

The most common and dangerous cause that complicates and slows down the biology of the wound process is the development of infection in the wound. It is in the wound that microorganisms find the most favorable living conditions with the necessary humidity, comfortable temperature, and an abundance of nutritious foods. Clinically, the development of infection in a wound is manifested by its suppuration. Fighting the infection requires a significant exertion of the forces of the macroorganism, time is always risky in relation to the generalization of infection, the development of other severe complications.

Infection of the wound is facilitated by its gaping, since the wound is open for microorganisms to enter it. On the other hand, significant tissue defects require more plastic materials and more time to eliminate them, which is also one of the reasons for the increase in the wound healing time.

Thus, the speedy wound healing can be promoted by preventing its infection and by eliminating the gaping.

In most patients, the gaping is eliminated during the operation by restoring the anatomical relationship by layer-by-layer stitching of the wound.

Caring for a clean wound in the postoperative period is reduced primarily to measures to prevent its microbial contamination with a secondary, hospital infection, which is achieved by strict adherence to well-developed aseptic rules.

Prevention of contact infection is achieved by sterilization of all items that may come in contact with the wound surface.

Surgical instruments, dressings, gloves, surgical linen, solutions, etc. are subject to sterilization.

Directly in the operating room, after suturing the wound, it is treated with an antiseptic solution (iodine, iodonate, iodopyrone, brilliant green, alcohol) and closed with a sterile bandage, which is tightly and securely fixed by bandaging or using glue, adhesive plaster. If in the postoperative period the dressing is lost or is soaked in blood, lymph, etc., you must immediately notify the attending physician or the doctor on duty, who, after examination, instructs to change the dressing.

A properly applied bandage completely covers the diseased area of \u200b\u200bthe body, does not disturb blood circulation and is convenient for the patient. When applying a bandage, it is necessary that the patient is in a comfortable position for him without tension. The bandaged part of the body should be motionless, easily accessible for bandaging and be in the position in which it will be after applying the bandage. When bandaging, it is necessary to observe the patient in order to see his reaction (pain, excessive compression, etc.). Bandaging is performed with an open bandage, usually from left to right clockwise, starting from the fixing round of the bandage. The head of the bandage is rolled in one direction, without tearing it off the bandaged surface so that each subsequent revolution covers half or two-thirds of the previous one. Bandaging begins from the periphery of the limb, roll out the bandage with one hand, and hold and straighten the bandage with the other. In some cases, for a tighter fit of the bandage, it is necessary to twist it every 2-4 turns of the bandage, especially often when bandaging the forearm and lower leg. The end of the bandage is fixed on the side opposite to the lesion site so that the knot does not interfere with the patient. With any dressing (removal of a previously applied dressing, examination of the wound and medical manipulations on it, application of a new dressing), the wound surface remains open and more or less for a long time comes into contact with air, as well as with instruments and other items used in dressing. Meanwhile, the air of dressing rooms contains significantly more microbes than the air of operating rooms, and often of other hospital rooms. This is due to the fact that more people are constantly circulating in the dressing rooms: medical staff, patients, students. Putting on a mask when dressing is mandatory to prevent droplets from getting on the wound surface with saliva splashes, coughing, breathing.

After the overwhelming majority of clean operations, the wound is sutured tightly. Occasionally, a drainage tube or a strip of glove rubber is left between the adjacent edges of the wound. Sometimes drainage is removed through a separate skin puncture to the side of the suture area. Wound drainage is performed to remove wound secretions, blood residues and accumulating lymph in the postoperative period in order to prevent wound suppuration. Most often, clean wounds are drained after breast surgery, when a large number of lymphatic vessels are damaged, or after operations for extensive hernias, when pockets in the subcutaneous tissue remain after removal of large hernial sacs.

Distinguish between passive drainage, when the wound exudate flows by gravity. With active drainage or active aspiration, the contents are removed from the wound cavity using various devices that create a constant vacuum in the range of 0.1-0.15 atm. Rubber cylinders with a sphere diameter but less than 8-10 cm, industrially manufactured corrugations, as well as modified aquarium microcompressors of the MK brand are used as a source of vacuum with equal efficiency.

Postoperative care of patients during vacuum therapy, as a method of protection of an uncomplicated wound process, is reduced to monitoring the presence of a working vacuum in the system, as well as to monitoring the nature and amount of wound discharge.

In the immediate postoperative period, air may be sucked in through skin sutures or leaking joints of tubes with adapters. When the system is depressurized, it is necessary to re-create a vacuum in it and eliminate the source of air leakage. Therefore, it is desirable that the device for vacuum therapy have a device for monitoring the presence of vacuum in the system. When using a vacuum of less than 0.1 atm, the system stops functioning on the first day after the operation, since the tube is obturated due to thickening of the wound exudate. When the degree of rarefaction is more than 0.15 atm, the lateral openings of the drainage tube are blocked by soft tissues with their involvement into the drainage lumen. This has a damaging effect not only on fiber, but also on young developing connective tissue, causing bleeding and increasing wound exudation. A vacuum in the range of 0.1-0.15 atm allows you to effectively aspirate discharge from the wound and provide a therapeutic effect on the surrounding tissues. The contents of the collectors are evacuated once a day, sometimes more often - as they fill up, the amount of liquid is measured and recorded.

The collection jars and all connecting tubes are pre-sterilized cleaning and disinfection. They are first washed with running water so that no clots remain in their lumen, then they are placed in a 0.5% solution of synthetic detergent and 3% hydrogen peroxide for 2-3 hours, after which they are washed again with running water and sterilized in an autoclave or dry-oven. If there was suppuration of the operating wound or the operation was initially performed for a purulent disease, then the wound must be carried out in an open way, that is, the edges of the wound should be diluted, and the wound cavity should be drained in order to evacuate pus and create conditions for cleansing the edges and bottom of the wound from necrotic tissues.

Working in the wards for patients with purulent wounds, it is necessary to adhere to the rules of asepsis no less scrupulously than in any other department. Moreover, it is more difficult to ensure the asepticity of all manipulations in the purulent department, since it is necessary to think not only about not only contaminating the wound of a given patient, but also about how not to transfer the microbial flora from one patient to another. "Superinfection", that is, the introduction of new microbes into a weakened organism, is especially dangerous.

It is necessary to carefully monitor the condition of the dressing, which must remain dry and not contaminate linen and furniture in the ward. Bandages often need to be bandaged and changed.

The second important sign of a wound is pain, which occurs as a result of organic damage to nerve endings and itself causes functional disorders in the body. The intensity of pain depends on the nature of the wound, its size and location. Patients perceive pain in different ways and respond to it individually.

Intense pain can be the trigger for collapse and shock. Severe pains usually absorb the patient's attention, interfere with sleep at night, restrict the patient's mobility, in some cases cause a feeling of fear of death.

Pain management is one of the necessary tasks in the postoperative period. In addition to prescribing medications for the same purpose, elements of direct impact on the lesion are used. During the first 12 hours after surgery, an ice pack is placed on the wound area. Local exposure to cold has an analgesic effect. In addition, cold causes contraction of blood vessels in the skin and underlying tissues, which promotes thrombus formation and prevents the development of hematoma in the wound.

To prepare "cold", water is poured into a rubber bubble with a screw cap. Before screwing on the cap, the air must be forced out of the bubble. Then the bubble is placed in the freezer until it is completely frozen. The ice bubble should not be placed directly on the strap, it should be placed under a towel or a napkin.

To reduce pain, it is very important after the operation to give the affected organ or part of the body the correct position, which maximizes muscle relaxation and functional comfort for the organs.

After operations on the abdominal organs, a functionally advantageous position with a raised head end and slightly bent knees, which promotes relaxation of the abdominal press and provides peace to the surgical wound, favorable conditions for breathing and blood circulation.

The operated limbs should be in an average physiological position, which is characterized by balancing the action of antagonist muscles. For the upper limb, this position is abduction of the shoulder to an angle of 60 ° and flexion to 30-35 °, the angle between the shoulder and forearm should be 110 °. For the lower limb, flexion in the knee and hip joints is performed up to an angle of 140 ° and the foot should be at right angles to the lower leg. After the operation, the limb is immobilized in this position using splints, splints or fixing bandages.

Immobilization of the affected organ in the postoperative period greatly facilitates the patient's well-being by relieving pain.

With purulent wounds in the 1st phase of the wound process, immobilization helps to delineate the infectious process. In the regeneration phase, when the inflammation subsides and the pain in the wound weakens, the motor regime expands, which improves the blood supply to the wound, promotes early healing and restoration of function.

Fighting bleeding, the third important sign of a wound, is a major challenge in any surgery. However, if for some reason this principle turned out to be unrealized, then in the next few hours after the operation, the dressing is blotted with blood or bleeding through the drainages. These symptoms serve as a signal for an immediate examination by the surgeon and active actions in terms of revision of the wound in order to finally stop bleeding.

If, under any conditions in a non-standard environment, you receive a wound, you need to properly treat it, otherwise you risk getting suppuration. A festering wound can lead to the most tragic consequences.

One of the important risk factors for suppuration is the ingress of foreign objects into the wound: earth, dirt, pieces of clothing and other other third-party inclusions. Under these conditions, there are all conditions for the development of suppuration. As practice and experience show, any untreated wound, practically always leads to the fact that it is most likely to fester.

Signs of suppuration

The development of the infection earlier, is characterized by increased pain, pulsation and distention. Puffiness and hyperemia become noticeable, after which the separation of pus begins. The scarring process can be largely inhibited with wound suppuration. In addition, this is a clear threat of the spread of infection, which is fraught with sepsis and can be fatal.

The most dangerous are wounds with a putrid infection resulting from infection with gas gangrene, tetanus and rabies.

In addition to increased pain and swelling, a change in tissue color is also observed. Fibrinous clots become dark gray in color, and the amount of pus that is separated increases.

With the deterioration of the course of the suppuration process, the temperature can rise to 39 - 40C, while signs of general intoxication will clearly be traced.

If, in the absence of pain, the patients experience a chill, the addition of a putrefactive process should be suspected.

Festering wound treatment process

Tools and materials used for dressing a purulent wound must be sterile or thoroughly disinfected.

Bandaging of purulent wounds should be carried out every day, and in the case of extensive suppurations that occur against the background of severe intoxication - twice a day.

Obligatory dressing is carried out in case of obvious getting wet. An additional indication for an extraordinary dressing is increased pain in the wound.

When bandaging, the first thing to do is remove the bandage and bandage. Since the lower layers of the bandage are infected, it should not be twisted, but cut with scissors without unwinding. The skin needs to be held, not allowing it to reach behind the bandage. A bandage that is firmly adhered to the wound should be soaked with a cotton-gauze swab moistened with hydrogen peroxide, furacilin or saline.

If capillary bleeding begins when the dressing is removed, this place is clamped with a sterile gauze napkin, and only after the blood stops, the skin around the wound is treated.

The area around the wound is treated with iodine or alcohol, and the site of the festering wound is cleaned with sterile dry tampons, and after that it is thoroughly washed with an antiseptic solution, which can be chlorhexidine, hydrogen peroxide or collargol.

Necrotic areas of tissue, which begin to exfoliate, are gently grasped with tweezers and cut with sharp sterile scissors.

Like any other, purulent inflammation is the body's response to the effect of any stimulus, aimed at limiting the pathological site, destroying provoking agents and restoring damage. The inflammatory response consists of three successive phases: injury, edema, recovery. It is the nature of the edema that determines the type of inflammation.

Purulent inflammations develop with the predominance of pathogenic pyogenic bacteria in the edematous fluid (exudate). It can be Pseudomonas aeruginosa and Escherichia coli, staphylo-, gono-, streptococci, Klebsiella, Proteus. The degree of bacterial contamination of the lesion determines the likelihood and nature of the inflammatory reaction.

Pus is a liquid medium containing dead blood cells (leukocytes, phagocytes, macrophages), microbes, enzymes (proteases), destroyed and dead tissues, fats, protein fractions. It is proteases that are responsible for tissue dissolution (lysis) at the site of injury.

The following types of purulent inflammation are distinguished:

• empyema - an accumulation of pus in a cavity represented by the walls of an organ;
• abscess - a cavity resulting from tissue melting, filled with purulent exudate;
• phlegmon - spilled purulent along the vessels, nerves, in the fascia.

One of the most common benign tumors in the subcutaneous tissues is atheroma. It is formed in the places of greatest distribution of the sebaceous glands: head, coccyx area, face, neck. Atheroma has the appearance of a rounded formation, is a cavity enclosed in a capsule, containing fat, cholesterol, and skin cells.

It occurs as a result of the clogging of the excretory duct of the sebaceous gland. Atheroma can be single, but in most cases there is a multiple distribution of these formations of various sizes. This tumor is painless and, apart from cosmetic discomfort, does not cause any inconvenience.

There are primary (congenital) and secondary atheromas that occur with seborrhea. On palpation, they are dense, moderately painful, and have a bluish tint. Secondary tumors are localized on the face, chest, back, neck. After their opening, ulcers with undermined edges are formed.

In outpatient surgery, inflammation of atheroma is a common problem. The predisposing factors for this are the following conditions:

• lack of hygiene;
• self-squeezing acne, especially if antiseptic rules are not followed;
• microtrauma (scratches and cuts);
• pustular skin diseases;
• decreased local immunity;
• hormonal disorders;
• abuse of cosmetics.

Suppurative atheroma is characterized by soreness, local redness and swelling. At large sizes, fluctuation can be noted - a feeling of fluid overflow in the elastic cavity. Sometimes the formation breaks through on its own and fatty pus is released.

Inflammation of atheroma is treated only surgically. A skin incision is performed, the contents are exfoliated with the obligatory removal of the capsule. When it is not completely removed, a relapse is possible after the operation. If atheroma has re-formed, inflammation can develop in the same area.

Suppuration of wounds

Wounds arise for numerous reasons: domestic, industrial, criminal, military, after surgery. But inflammation of the wound is not always purulent. It depends on the nature and location of damage, tissue condition, age, microbial contamination.

The factors that predispose to inflammation of the wound surface are as follows:

• injury by a contaminated object;
• non-compliance with hygiene rules;
• the use of steroid hormones and / or cytostatics;
• excess body weight;
• malnutrition;
• vitamin deficiency;
• elderly age;
• decreased local and general immunity;
• chronic skin diseases;
• severe somatic diseases;
• hot, humid weather;
• insufficient drainage of the wound after surgery.

Usually, wound suppuration is characterized by the fact that purulent inflammatory exudate accumulates in the tissue defect. At the same time, hyperemia (redness) and "warm" edema appear around the edges due to vasodilation. In the depths of the wound, "cold" edema prevails, associated with impaired lymphatic outflow due to vascular compression.

Against the background of the listed signs, bursting, pressing pain appears, and the temperature is locally elevated in the affected area. A necrotic mass is determined under the layer of pus. Absorbed into the blood, decay products, toxins cause symptoms of intoxication: fever, weakness, headaches, decreased appetite. Therefore, if there is an inflammation of the wound, treatment should be immediate.

Suppuration of postoperative sutures

The process of inflammation of the postoperative suture occurs, as a rule, 3-6 days after surgical procedures. This is due to the ingress of pyogenic microorganisms into the place of tissue damage. Bacteria can be introduced into the wound primarily (by the subject of injury, poorly processed instruments, by the hands of medical personnel and / or the patient himself) and indirectly from the focus of chronic infection: caries, tonsillitis, sinusitis.

Factors predisposing to the development of the pathological process in the seam area:

• insufficient disinfection of medical equipment;
• non-observance of the rules of asepsis, antiseptics;
• reduced immunity;
• poor drainage of the separated wound;
• damage to the subcutaneous tissue (hematomas, necrosis);
• poor quality suture material;
• non-compliance with patient hygiene;
• areas of ischemia (lack of blood supply) due to clamping of vessels with ligature.

If inflammation of the seam has developed, then symptoms such as redness and swelling of the skin around, soreness will be observed. First, a serous fluid mixed with blood can be separated from the seam, and then suppuration occurs.

With a pronounced process of inflammation, fever with chills, lethargy, refusal to eat appear.

A festering surgical suture should be treated only under medical supervision. Wrong independent actions can lead to the spread of infection, deepening of inflammation and the development of formidable complications up to. In this case, a rough convoluted scar is formed.

Purulent lesions of the skin and subcutaneous tissue

Pathological processes in the skin and underlying layers are very common in surgical practice. The skin and its appendages are the body's first protective barrier against various adverse effects.

The negative factors provoking the development of skin inflammation are:

• mechanical damage (scratches, abrasions and cuts, scratches);
• exposure to high and low temperatures (burns, frostbite);
• chemical agents (household alkalis, acids, abuse of antiseptic and detergents);
• excessive sweating and sebum secretion can cause purulent inflammation of the skin;
• poor hygiene (especially in obese people);
• diseases of internal organs (pathology of the endocrine, digestive systems;
• ingrown nail.

Microbes brought in from the outside and / or representatives of opportunistic flora can cause purulent inflammation of the skin and subcutaneous tissue. Skin suppurations are varied according to the site of localization and clinical course.

Furuncle

Suppuration and sebaceous gland - boil. It can be localized to areas of the skin where there is hair. It occurs at any age. Most often found in patients with diabetes and / or obesity.

Clinical manifestations are expressed in typical inflammation: hyperemia, pain, increased local temperature, swelling. Sometimes this condition is accompanied by a reaction of closely located lymph nodes.

Lymphadenitis, abscess, thrombophlebitis (inflammation of the veins), phlegmon, reactive purulent arthritis, sepsis, meningitis can become complications of furunculosis.

Carbuncle

Carbuncle is an acute infectious inflammation of several hair follicles with sebaceous glands at the same time. It occurs more often in people of mature and old age. Endocrine disorders play an important role in the development of this inflammation. Typical localization is the back of the neck, back, abdomen, buttocks.

At the site of infection, a dense diffuse edema occurs, the skin becomes purple and painful. Necrotic tissue melting occurs. The carbuncle is opened in several places, creamy pus is released. The defeat with such inflammation of the skin looks like a honeycomb.

Hydradenitis

Inflammation of the sweat glands occurs mainly with untidiness, diaper rash, and scratching. The first place among the provoking factors is shaving the armpits. Microtrauma to the skin occurs, and the use of a deodorant contributes to the blockage of the excretory ducts of the glands.

In the armpit, a dense, painful tubercle forms, the skin becomes purple-cyanotic. As the inflammation develops, the pain intensifies and interferes with movement. There is a fluctuation, the skin in the center becomes thinner, and thick pus breaks out.

With the spread of inflammation to other areas, due to the abundance of lymphatic tissue, a conglomerate of nodes with protruding papillae of the skin is formed - "bough udder". If no treatment is carried out, the process can spread - an abscess or phlegmon is formed. Sepsis is a formidable complication of hydradenitis.

Abscess

A cavity of a purulent-necrotic nature, limited by a capsule, is an abscess. More often occurs as a complication of inflammation, pustular diseases on the skin.

The cause of the development of a purulent cavity can be inflammation of a puncture wound or injection site, when the outflow of pus is impaired.

Clinically, an abscess is manifested by edema and hyperemia of the skin in the affected area. A densely elastic painful formation is palpable deep in the tissues. The skin over the abscess is hot to the touch. Symptoms of intoxication appear.

When an abscess is opened and incomplete emptying or the presence of a foreign body in the cavity, the walls of the capsule do not close completely, and a fistula is formed. A breakthrough of pus can occur on the skin, into the surrounding tissues, into the cavity of the organs.

Phlegmon

A purulent-necrotic process of inflammation located in the cellular space, which does not have clear boundaries. The causes of phlegmon are the same as with an abscess.

Due to the development of aesthetic medicine, the formation of phlegmon can be provoked by corrective procedures: liposuction, the introduction of various gels. Localization sites can be any, but more often the areas of the abdomen, back, buttocks, and neck tend to become inflamed. Not uncommon - damage to the tissues of the leg.

Gradually melting tissue, phlegmon spreads through the tissue, fascial spaces, destroying blood vessels and provoking necrosis. Often abscess, hydradenitis, furuncle are complicated by phlegmon.

Paronychium and panaritium

Panaritium is an inflammation of soft tissues, bones and joints of the fingers of the hand, less often of the foot. The pain of panaritium can be unbearable, sleep deprivation. At the site of inflammation - hyperemia and edema. With the development of the process, the function of the finger is disrupted.

Depending on the localization of the lesion, panaritium can be of different types:

• cutaneous - the formation of suppuration between the epidermis and the next layers of the skin with the formation of a "bubble";
• subungual - pus flowed under the nail plate;
• subcutaneous - a purulent-necrotic process of the soft tissues of the finger;
• articular - damage to the phalangeal joint;
• tendon - tendon suppuration (tendovaginitis);
• bone - the transition of a purulent process to the bone, proceeding as osteomyelitis.

Paronychium - damage to the roller near the nail. maybe after a manicure, cuticle cutting. In this condition, throbbing pain, redness, and separation of pus are noted.

Treatment

Surgery is involved in purulent inflammation of the soft and other tissues of the body. When symptoms appear that indicate a purulent lesion, it is imperative to consult a doctor. Self-treatment is fraught with the spread of the process and the aggravation of the situation. The main directions of treatment:

The following methods are used for the surgical treatment of wounds:

• physical (laser radiation, plasma flows, vacuum treatment of the inflammation zone);
• chemical (various enzyme preparations: Trypsin, Chymotrypsin, Lysosorb);
• biological (removal of necrotic tissue by the larvae of green flies).

With conservative therapy, the following drugs are used:

• antiseptics (Povidone iodine, Miramistin, Ethacridine, Chlorhexidine);
• water-soluble ointments (Dioxidin, Methyluracil);
• creams (Flamazin, Argosulfan);
• drainage sorbents (Collagenase);
• aerosols (Lifuzol, Nitazol).

In the period of regeneration (healing) after the operation, the following means are used:

• dressings with antibacterial ointments (Levomekol, Tetracycline, Pimafucin), stimulating substances (Vinilin, Actovegin, Solcoseryl);
• special wound dressings against inflammation and for healing (Voskopran);
• preparations based on natural polymers (Algipor, Kombutek).

Purulent inflammation of various parts of the body is common and takes many different forms. The course of the process can be smooth or bring formidable complications leading to death. Therefore, treatment must be approached in a comprehensive manner and carry out the whole range of prescribed therapeutic measures, preventive measures to prevent the secondary occurrence of the disease.